Management of Valvular Heart Disease in Adults
Management of Valvular Heart Disease in Adults
- Howard C. Herrmann, MD
New guidelines emphasize stages of disease progression and guideline-directed medical therapy and include clinically relevant decision-pathway algorithms.
- Howard C. Herrmann, MD
Sponsoring Organization: American College of Cardiology, American Heart Association
Target Population: Primary care providers, cardiologists
Background and Objective
In 2013, the estimated prevalence of valvular heart disease (VHD) in the U.S. was 2.5% overall and as high as 12%–13% in adults aged ≥75. These new guidelines for the management of VHD in adults are based on evidence or expert consensus and replace the previous guidelines (fully revised in 2006 and updated in 2008).
—A new classification paradigm applies to the stages of VHD progression:
A = at risk
B = progressive (mild to moderate and asymptomatic)
C = asymptomatic and severe
D = symptomatic and severe
Stage C is subdivided into compensated (C1) or decompensated (C2) left or right ventricular function.
—Transthoracic echocardiography (TTE) should be used in the initial evaluation of patients with known or suspected VHD (Class I recommendation), and frequency of follow-up TTE in asymptomatic (stage B and C) patients is specified by stage and lesion. Symptomatic patients with inconclusive noninvasive-test findings should undergo catheterization (Class I), and exercise testing can be useful in selected asymptomatic patients (Class IIa).
—Recommended assessment of surgical or interventional risk incorporates Society for Thoracic Surgeons predicted risk for mortality, frailty, major organ-system compromise (comorbidity), and procedure-specific impediments (e.g., hostile chest or porcelain aorta), yielding risk designations of low, intermediate, high, and prohibitive.
—Patients considering interventional treatment for severe VHD should undergo assessment by a multidisciplinary Heart Valve Team (Class I). Referral to a Heart Valve Center of Excellence is reasonable for those who are asymptomatic, might benefit from repair versus replacement, or have multiple comorbidities (Class IIa).
—Stage D aortic stenosis (AS) is subdivided as follows:
D1: high-gradient (>40 mm Hg)
D2: low-flow, low-gradient, reduced ejection fraction (EF)
D3: paradoxical low-flow, low-gradient, normal EF
Class I recommendations for aortic valve replacement (AVR) in patients with AS include stages D1 and C2 (asymptomatic with high gradient and reduced EF). Detailed, specific Class IIa AVR recommendations are provided for stages B, C1, D2, and D3.
—Transcatheter aortic valve replacement (TAVR) is recommended in patients with AS who meet criteria for AVR, have prohibitive surgical risk, and are expected to survive longer than 12 months post-procedure (Class I). TAVR is reasonable in high-risk patients with AS after Heart Valve Team assessment (Class IIa), but surgery is recommended in low- and intermediate-risk patients (Class I). Balloon aortic valvuloplasty may be a reasonable bridge to surgical or transcatheter AVR in patients with stage D AS (Class IIb).
—Recommendations for surgical AVR in patients with severe, asymptomatic aortic regurgitation (stage C) are as follows:
Class I: reduced EF (stage C2)
Class IIa: normal EF, left ventricular end-systolic dimension (LVESD) >50 mm
Class IIb: normal EF, left ventricular end-diastolic dimension (LVEDD) >65 mm with low surgical risk
Those with LVEF >50%, LVESD <50 mm, and LVEDD <65 mm should receive periodic monitoring.
—These guidelines adopt an increasingly popular classification of chronic mitral regurgitation (MR) as primary (degenerative) or secondary (functional). Primary disease affects the valve components and includes prolapse, Barlow's valve, and fibroelastic deficiency. In secondary MR, the valve is normal, and MR results from left ventricular dysfunction (ischemic or nonischemic). Importantly, echocardiographic and hemodynamic criteria for severity differ between the two classes.
—Mitral valve surgery is recommended in patients with stage D or stage C2 primary MR. Mitral valve repair is reasonable in stage C1 patients if the likelihood of successful, durable repair exceeds 95%; or if the lesion is nonrheumatic, atrial fibrillation or pulmonary hypertension has developed, and successful, durable repair is likely (Class IIa). Transcatheter repair is recommended in stage D patients with reasonable life expectancy and prohibitive surgical risk if guideline-directed medical treatment is unsuccessful (Class IIb).
—Mitral valve surgery is reasonable in patients with stage C or stage D secondary MR who are undergoing AVR or coronary artery bypass grafting (Class IIa), and may be considered in stage D patients who are not undergoing other procedures but whose symptoms are severe (Class IIb).
—Additional comprehensive recommendations are provided for less-common VHDs, including mitral stenosis and tricuspid disease; management of VHD during pregnancy; and bridging anticoagulant therapy during invasive procedures in patients with prosthetic valves.
These guidelines introduce several new concepts and paradigms for VHD — including stages of disease progression — and feature decision-pathway diagrams to facilitate quick access to clinically relevant information. They incorporate new treatments (TAVR and transcatheter mitral repair) and more-comprehensive risk assessment into decision making for interventional treatments.
Although the new A-to-D classification of disease progression may be confusing at first, it provides a useful framework for considering when to intervene. Beyond prevention of rheumatic heart disease and adherence to guideline-directed medical therapy, the guidelines have little to offer for preventing or slowing the progression of valvular heart disease in stages A and B. In stage C, however, the guidelines emphasize the use of risk stratification, Heart Valve Teams, referral to Heart Valve Centers of Excellence when appropriate, and patient involvement in decision-making to identify the optimal timing of intervention.
Editor Disclosures at Time of Publication
Disclosures for Howard C. Herrmann, MD at time of publication Consultant / Advisory board Gerson Lehrman Group; Siemens; St. Jude Medical Speaker's bureau American College of Cardiology Foundation; Cardiovascular Institute; Cardiovascular Research Foundation; Christiana Medical Center; Coastal Cardiovascular Society; Crozer-Chester Hospital; Mayo Clinic; New York Cardiology Society Equity Micro-Interventional Devices, Inc. Grant / research support Abbott Vascular; Edwards Lifesciences; Gore; Medtronic; St. Jude Medical Editorial boards Catheterization and Cardiovascular Interventions; Circulation-Cardiovascular Interventions; Journal of Interventional Cardiology; Journal of Invasive Cardiology
Reader Comments (5)
Since the aortic valvular disease frequently is accompanied by a dilation of the ascending aorta, especially in bycuspid aortic valve, I would have introduced in the new guidelines the indications to the replacement of the aortic valve, not only taking into account symptoms and left ventricular function, but also the size of the ascending aorta.
User friendly classification for valvular heart disease
Appropriate recommendations and clear categorisation.
I think that this is a very good article.